Cervical Cancer: Building Bridges, Making Progress

Cervical Cancer: Building Bridges, Making Progress

I never thought I would see the day when two abstracts about cervical cancer would be included as plenary presentations at the Annual Meeting. Cervical cancer, after all, is a rare disease in the U.S. and developed countries— we have access to cervical cancer screening programs and the HPV vaccine. Therefore, although cervical cancer can be a devastating disease (and a frustrating one for those of us who specialize in gynecologic oncology), the results of clinical trials rarely warrant a central platform for presentation.

However, this year's ASCO was different. Two very important and very different studies related to cervical cancer were shared—and I am happy that the Program Committee recognized their significance. For me, they illustrate the bridges that need to be built and the chasms of care that need to be addressed on a global scale.

The first study evaluated screening for cervical cancer in India, where formal screening programs are not practical or feasible. This study, presented by Dr. Surendra Shastri, evaluated the impact of visual inspection with acetic acid (VIA) on cervical cancer mortality. Two cohorts were recruited in this planned 16-year study; both had access to cancer education but only one cohort was additionally followed with four rounds of VIA. The take home message was that VIA saves lives. The age-adjusted mortality rate (AAR per 100,000 women-years of observation) with VIA was 14.4, instead of almost 20 without VIA, translating into a 30% reduction in the risk of death. Estimates are that this simple procedure would save almost 22,000 women a year in India alone.

The other study featured the results of Gynecologic Oncology Group (GOG) 240, a randomized trial in women with advanced, recurrent, or metastatic cervical cancer who were randomly assigned to chemotherapy with or without bevacizumab. As presented by Dr. Krishnansu Tewari, the addition of bevacizumab increased response rates (48 versus 36% with chemotherapy alone) and even more importantly, resulted in the first improvement in overall survival seen in several decades of clinical trials, with the median survival extending from 12 to 16 months, translating into a nearly 30% improvement in overall survival. These results should indeed change practice and represents a significant achievement for this population.

While the results of these studies represent huge gains in the approach to cervical cancer, they also illustrate the dilemma we face as a global community of oncologists. On the one hand, investigators in the US and abroad are dedicated to finding ways to reduce the mortality of cervical cancer in areas where cervical cancer screening programs cannot be implemented, as Dr.Shastri stated in his plenary presentation, “because of inadequate infrastructure, lack of trained personnel, logistical barriers, and the relatively high costs”. For women in these countries, this study has shown that VIA can impact mortality. However, one should not consider VIA as the penultimate solution. Even with VIA, the mortality rate is still too high compared to western countries. Indeed, the latest Surveillance, Epidemiology, and End Results (SEER) program results places the ARR in the US at 7.9.

On the other hand we have the results of GOG240 where incorporation of bevacizumab has finally given us a treatment that extends median survival beyond one year. Still, faced with the sobering reality that the burden of cervical cancer is not in the US or other “developed” countries, but rather is within underdeveloped countries, we must acknowledge that the results of GOG240 are not likely going to change the pattern of care in the areas where the need is greatest (whether they be outside of the US or within the US). As I listened enthusiastically to the results of GOG240, I am left wondering- What good is it to improve survival if that treatment is out of reach for the majority of women living with this disease?

I truly believe we as a global Oncology community must work together to continues to address cancer prevention AND cancer treatment. Although the screening study shows that doing “something” is indeed better than doing “nothing”, we should continue to see how we can do better in these areas. In addition, with the results of GOG240, we must address disparities head-on and advocate for access to new agents, and we must do so as a global oncology community. Fortunately, I believe that ASCO is well-positioned to lead in these charges and I know we will be not alone in our international efforts.

Congratulations to the authors, to Drs. Swain, Yee, and Tan for a wonderful plenary session.

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Comments

Yousuf Zafar, MD, MHS

Jun, 05 2013 10:32 PM

Don, great post. I completely shared your enthusiasm around these trials, particularly Dr. Shastri's study. I ran into him at the airport after the meeting and practically gushed (it was embarrassing). Much credit goes to ASCO and Dr. Swain for highlighting a pivotal work in oncology in a low-income setting. At the level of a plenary, I believe this is a first, and as such, should be applauded.

Don S. Dizon, MD, FACP

Jun, 09 2013 7:06 AM

Thanks Yousuf. It's great to see your thoughtful insights on ASCO Connection. And thanks for your comments. ASCO 2013 was a great achievement, particularly for women. Progress in cervical cancer shared the stage alongside those made in other areas. Unlocking the genomics of cervical cancer remains the next frontier. Take care, D

Fatima Lilani

Jun, 10 2013 3:17 AM

Hi Don, I am part of a non-profit organisation in Pune, India working in the field of cancer management for over 15 years. As part of one of our projects, we run two clinics for women in the urban slums as a health maintenance program where we screen them for cervical cancer. We have a digital colposcope too. We are very low profile, however we have data of the last 15 years which I am sure would be helpful if one had to do a focussed study. Would love to have your insights and guidance on this. Regards, Fatima

Don S. Dizon, MD, FACP

Jun, 10 2013 8:30 AM

Dear Fatima,It sounds like you are doing wonderful work in an area of need. I would love to hear more about your work and if I can be of service, would be happy to oblige. Please contact me at ddizon@partners.org. I will look forward to hearing from you. D